Quote:"They have lost their nerve — they are not courageous. They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result. If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a Senate Inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

Although not an AAI, the following NTSB news presser (& executive summary) for the release of a high profile marine accident investigation IMO perfectly highlights the difference between a truly independent transport safety investigator, versus our version of a politically and commercially captured imitation of a TSI...

Page Content
WASHINGTON (Dec. 12, 2017) — The deadliest shipping disaster involving a U.S.-flagged vessel in more than 30 years was caused by a captain’s failure to avoid sailing into a hurricane despite numerous opportunities to route a course away from hazardous weather, the National Transportation Safety Board announced during a public meeting Tuesday.

“We may never understand why the captain failed to heed his crew’s concerns about sailing into the path of a hurricane, or why he refused to chart a safer course away from such dangerous weather,” said NTSB Chairman Robert L. Sumwalt. “But we know all too well the devastating consequences of those decisions.”

NTSB investigators worked closely with the U.S. military and federal- and private-sector partners to locate the wreckage, photo- and video-document the ship and related debris field, and recover the El Faro’s voyage data recorder from more than 15,000 feet under the surface of the sea.

El Faro at sea viewed from stern (Photo by William Hoey)

Color-enhanced satellite imagery of Hurricane Joaquin taken close to the accident time.
El Faro’s track is identified by the green line.

The ship departed Florida Sept. 29, 2015, and had a range of navigation options that would have allowed it to steer clear of the storm that later became a Category 4 hurricane. The captain, consulting outdated weather forecasts and ignoring the suggestions of his bridge officers to take the ship farther south and away from the storm, ordered a course that intersected with the path of a hurricane that pounded the ship with 35-foot seas and 100 mph winds.

As the ship sailed into the outer bands of the storm, about five hours prior to the sinking, its speed decreased and it began to list to starboard due to severe wind and seas. In the last few hours of the voyage, the crew struggled to deal with a cascading series of events, any one of which could have endangered the ship on its own.

Seawater entered the ship through cargo loading and other openings on a partially enclosed deck in the ship’s hull, pooled on the starboard side and poured through an open hatch into a cargo hold. The hold began to fill with seawater, and automobiles in the hold broke free of lashings and likely ruptured a fire main pipe that could have allowed thousands of gallons of seawater per minute into the ship – faster than could be removed by bilge pumps.

About 90 minutes before the sinking the listing ship lost its propulsion and was unable to maneuver, leaving it at the mercy of the sea. Although the captain ordered the crew to abandon ship when the sinking was imminent, the crew’s chances of survival were significantly reduced because El Faro was equipped with life rafts and open uncovered lifeboats, which met requirements but were ineffective in hurricane conditions.

The NTSB also said that the poor oversight and inadequate safety management system of the ship’s operator, TOTE, contributed to the sinking.

“Although El Faro and its crew should never have found themselves in such treacherous weather, that ship was not destined to sink,” said Sumwalt. “If the crew had more information about the status of the hatches, how to best manage the flooding situation, and the ship’s vulnerabilities when in a sustained list, the accident might have been prevented.”

As a result of the 26-month long investigation, the NTSB made 29 recommendations to the U.S. Coast Guard, two to the Federal Communications Commission, one to the National Ocean and Atmospheric Administration, nine to the International Association of Classification Societies, one to the American Bureau of Shipping, one to Furuno Electric Company and 10 to TOTE Services.

Now although this is an extremely high profile and complex marine accident investigation, it is worth noting that it took 2 years, 2 months to complete. It is also worth comparing the chronologically recorded investigation webpage - see here complete with the preliminary report and regular media updates - then review the latest (& presumably last) ATSB VH-NGA (re-)investigation webpage: https://www.atsb.gov.au/publications/inv...-2009-072/

One of the fundamental elements for an effective CASA approved FRMS, is the commitment by the Operator to embrace the philosophy of a 'just culture' within the context of a (now mandatory) CASA Safety Management System. This includes the ability for operational crew and maintenance personnel to submit hazard alert reports on fatigue related incidents, without fear of internal company retribution/reprisals.

Keeping the above historical (Malcolm Campbell signed) CASA 'safety alert' in mind, can anyone else spot the huge disconnect (in CASA oversight of the PelAir FRMS/SMS), when we revisit the following extracts (from page 266) - under the heading CASA oversight of specific system elements (prior to 18 November 2009) - of the PelAir MKII final report??

Quote:

"...There was no evidence these actions were communicated in writing to the operator, and no indication the operator formally responded. As far as could be determined, the nominated safety officer did not undertake FRMS training and no additional information was provided to pilots...

...Yet...

...Following the March 2009 meeting, CASA were satisfied the operator’s FRMS was operating satisfactorily and it reapproved the operator to conduct operations according to its approved FRMS for another 24 months..." - WTD??

Q1/ I wonder if the March 2009 meeting included the input from it's former PelAir overseeing FRMS specialist, and/or the former Human Factors manager Mr Ben Cook?

On reading Ben Cook's finding in his FRMS SAR I would suggest not, reference: CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

Then we have further proof that Wodger, and his merry band of Sydney Office psychopaths, further white washed the many documented and specialist identified deficiencies of the PelAir FRMS/SMS...

Extracts from pages 275-276:

Quote:

"...When the Sydney region manager advised CASA senior management of the safety alert, he noted he did not think the matter would escalate to a need to consider a ‘serious and imminent risk’, given that the operator was demonstrating a willingness to address the issue. However, he was considering what further action may be necessary..." Still waiting??- Obfuscation 101: "Simply deny there is an issue, worst case if some disgruntled employee kicks up a fuss and attempts to submit a HAZARD report; or leak again to some CASA HF expert; we'll slam the individual with some petty enforcement threat; or if there is an occurrence then we'll just throw the book at the pilot"

Hmm...what say you "K" how does that stack up against one Airtex or Barrier AOC embuggerance?

P2 – “Hmm...what say you "K" how does that stack up against one Airtex or Barrier AOC embuggerance?”

The post above defines the P2 pawky sens’aumour. Shall I take the bait; or like an old Pike lay doggo in the cool, green depths of the swamp. Maybe, just maybe, I’ll swim past his bait, give it a nudge and watch the results.

P2 knows, as well as I do the implications of his research. What the ‘Bankstown crowd have been doing for the last seven years will not withstand any serious investigation. The post above provides the erudite reader with enough clues to fathom the riddle. Fact and evidence gathered and consolidated will weigh heavily against this crew of clowns, halfwits and malcontents. The pure hatred of an industry which rejected them, the venom against those who would not countenance their presence on a ‘professional’ flight line and their pathetic attempts to influence anything remotely resembling their deepest desire – to belong – make them beneath contempt. Soon, gods willing, the disgraceful, deceitful actions of this particularly dysfunctional crew will be revealed – then we shall see. For he laughs last, laughs best.

IMO very much related - to the attitude of the psychopath Sydney CASA office (back then & apparently still now) to FRMS/SMS - I cribbed the following links etc. off this UP thread: UNSW Fatigue Report 2017

Haven't gone through the whole report yet but if the 'executive summary' is anything to go by the report is going to make for some disconcerting reading...

Quote:Executive Summary
This report describes the findings of an independent survey of 1,132 Australian commercial pilots on their experiences of fatigue while working under CAO 48.0 and various exemptions currently allowed by CASA. The survey was conducted on-line by Transport and Road Safety (TARS) Research at the University of New South Wales (UNSW Sydney). Invitations to participate were sent by the Australian Federation of Air Pilots (AFAP) to all their members and advertisements inviting all commercial pilots to take part in the survey were placed in the fortnightly Aviation pages of The Australian newspaper over four weeks in June-July 2017.

The findings show that fatigue is a significant problem for Australian commercial pilots. Around half of pilots surveyed (52.4%) reported that fatigue is a substantial or major personal problem in their work. The majority had experienced fatigue both before or during duty at some stage in their flying career. Approaching half (46.1%) had experienced fatigue during half or more of their shifts.

Pilots reported significant consequences of experiencing fatigue. Almost all reported that fatigue had produced negative effects on performance. Over two-thirds had made an error due to fatigue at some stage and nearly half (45%) had experienced a microsleep while on duty and one in five had fallen asleep unplanned while on the flight deck.

Regression modelling of the major contributors to experiencing fatigue as a personal problem highlighted long duty periods including high flying hours, flying three sectors or more, night duties and inconsistent roster patterns as work-related factors and short recovery time and insufficient on-board rest as rest-related factors that significantly increased the odds of experiencing a fatigue problem.

Most pilots managed fatigue through use of caffeine-containing drinks and standing up and moving around, strategies that are easily accessible to all pilots. Controlled rest and napping, strategies that have longer term effectiveness for fatigue management but are more difficult to arrange, were used by a minority of pilots. Nearly 40 percent of pilots reported that they worked under a formal Fatigue Risk Management System (FRMS). Just over half (58%) had ever made a fatigue report but nearly half had reported sick instead of fatigued. Over half of pilots felt that their company always encouraged reporting of fatigue, but the most common reasons for not reporting were that they perceived no benefits in reporting or that there was likely to be an adverse response from the company if they reported. Nearly one-quarter didn’t report as they felt too tired and couldn’t be bothered.

Now compare that summary to the 'executive summary' from the Ben Cook PelAir FRMS special audit report:
Then remember how that report was given short shrift by McCormick in CASA's second supplementary submission to the Senate PelAir cover-up Inquiry:
Reference http://auntypru.com/wp-content/uploads/2...13_WEB.pdf
Is it any wonder that Ben Cook pulled the pin with CASA and that a large percentage of the pilot fraternity to this day still have no faith in FRMS and/or CAO 48.1...

Before we continue to follow the CASA breadcrumb trail of tick-a-box oversight of FRMS/SMS, the following are quote extracts from the last two entries to the now strangely - - dormant published ATSB REPCON archive: https://www.atsb.gov.au/repcon_reports/?mode=Aviation

Quote:Reporter's concern

The reporter expressed a safety concern related to the lack of organisational accountability shown by [operator] when their crewing department contacts flight crew, on their rostered day off, within three to four hours of sign on, to request that they accept an additional ‘back of clock’ duty.

The reporter advised that on multiple occasions they have been contacted by the crewing department to operate a ‘back of clock’ duty, as the pilot in command of a return flight from Sydney to either [location 1] or [location 2]. This involves a continuous duty of between 10:50 to 11:05, if there are no delays, at a time of low circadian rhythm. To operate these flights, the crewing officer was offering no less than $3,870 plus meal allowances on top of any normal remuneration. No questions were asked by the crewing department related to whether they were fit to accept the duty.

The reporter advised that even though it is a crew member’s responsibility to ensure that they are not fatigued before accepting the flight, [operator] also has a responsibility to ensure that the crew member is not fatigued.

Reporters comment: It appears evident that the crewing officers are making requests on a ‘Don’t ask, don’t tell’ basis as it relates to the rest that has been achieved by the flight crew member in spite of the ‘mutual responsibility’ to fatigue management.

This is concerning when considered in the context of the significant financial incentives, flight crew members have to self-define the meaning of ‘adequate rest’ as it relates to any given duty without any objective guidance provided for comparison.

The nature of fatigue on such a duty poses a significant risk to flight safety and the financial incentives for flight crew to either disregard or inadequately address such safety risks is of a compounding nature.

&..

Quote:Reporter's concern

The reporter expressed a general safety concern related to the recent management and oversight of [operator].

The reporter advised that under the previous organisational structures, the safety culture was changing and becoming more mature and safety focused. This seems to be reversing in recent times, with staff noticing a change in the focus of management's attitude, where safety is being prioritised after financial and organisational structural change. This has resulted in employees not having a clear direction when safety concerns are experienced.

The reporter advised that due to this, shortcuts are now being taken, where company and aircraft operating procedures are not being followed. The reporter also advised that the focus has changed to non-aviation matters, to the detriment of safety within the operational area. Staff members are still using the safety reporting system, but limited changes and lengthy review times, with many investigations remaining open is making staff lose faith in the system.

Reporter comment: I feel that a thorough investigation into the operation of the operator and the current management structure adopted is required to assist those people in the organisation who are attempting to adopt the safety culture required for an organisation such as this.

Now coming back to the PelAir MKII report the following is an extract from the 'Other factors which increased risk' (pg 354 of the 2nd report):

Quote:- Due to limited sleep in the previous 24 hours, the captain was probably experiencing a level of fatigue that has been demonstrated to adversely influence performance. - The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby
periods. [Safety issue]- Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days. [Safety issue]

And this was how the (top) 'safety issue' was apparently proactively addressed (since 2014??) by the operator:

After the accident, the operator undertook a series of actions to improve its fatigue management practices. These included:

- revised the callout time for air ambulance tasks from 2 hours to 3 hours
- developed and introduced a face-to-face introductory course on fatigue management and revised the content of the computer-based training course
- developed a fatigue assessment form to be used to assess the likelihood of fatigue prior to the assignment of ad hoc charter flights to flight crew who were on standby (with the form including a small number of questions to obtain basic information about a pilot’s recent sleep and rest)
- introduced a requirement to reduce the maximum period of 24 hour standby to 28 days (after which crew required a minimum of 8 days off duty)
- modified the FRMS to include longer required rest periods following duty periods involving large time-zone changes (more than 3 hours)
- conducted a workshop with a sample of the operator’s managers and flight crew (across all fleets) to identify fatigue hazards and risk controls.

In October 2017, the operator advised the ATSB:

Since the accident, continuous improvement and advancement has been made to the Pel-Air FRMS including the use of and understanding of the BMMF.

The FRMS has also become an integral part of the Pel-Air and Group Safety Management System and is a standing item that is tracked and reviewed by the Safety Management Group (SMG).

In addition to the existing recorded pro-active actions, other examples of development include;
- A formal Risk Assessment completed in relation to duty across different time zones and a set of guide lines were published as a result and the document (Acclimatisation Guidelines for Trans-Meridian Operations) is available to crew via the Flight Crew Notices Webpage.
- All Pel-Air crew, when submitting a report in the Safety Management System online reporting system, must select ‘Yes’ in relation to fatigue report, and submit all the required details, irrespective of whether or not fatigue is considered a contributing factor.- Further review, research and improvements were made in relation to the Extension of Duty assessment process.
- Completion of an FRMS Crew Survey.
- Pel-Air is also ISO 9001:2015 certified and holds BARS Gold Accreditation both of which are heavily weighted on the Safety Management System which include the FRMS.

Current status of the safety issue

Issue status: Adequately addressed
Justification: The ATSB notes the operator undertook several actions to address its risk
controls regarding fatigue management on its Westwind fleet, and more broadly across its operations. Although not every aspect of the safety issue was specifically addressed, the overall level of action reduced the risk of this safety issue.

If nothing else at least this time round the subject of fatigue and the FRMS was comprehensively reviewed and two 'safety issues' identified but the outstanding questions still remain:

Q/ Why didn't this same level of investigative scrutiny of the operator FRMS/SMS not occur with PelAir MK I?

&.. Reference email Steve W to Karen C in 2015:

Quote:Hi Karen

These three files summarise the concerns CASA had about PelAir's fatigue management as far back as 2004. This included an RCA (Request for Corrective Action) issued by CASA in May 2006 (2nd file) So there is long established history of CASA being concerned about fatigue management at PelAir.

The safety alert (a 2nd RCA) was issued in March 2008 (3rd file). This was quickly rectified, and there was a prompt return to FRMS operations.

So why did the 2009 audit devote 5 pages to fatigue management. The following quotes come from the 2009 audit.

•"Most crew identified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective." Page 22.
•There was an "FRMS knowledge gap displayed by the pilots." Page 22.
•"PelAir have not managed fatigue risk to a standard considered appropriate..." Page 23.
•No evidence was found that supported the claim that Pel-Air FRMS had ever managed fatigue risk to a standard considered appropriate, particularly for an operator conducting adhoc, back of the clock medivac operations.
•It is evident the fatigue reporting culture within Pel-Air is deficient. This cannot be fixed quickly, and will require a number of months to determine whether this reporting culture has improved. An open and honest reporting culture is critical to the success of any FRMS and there is evidence to suggest one or two key personnel may be the root cause of this cultural problem.

So CASA have concerns back at least as far as 2004. There were two RCA’s - 2006 and 2008. Yet CASA still find a litany of fatigue management problems in the 2009 post crash audit.

Very odd

Steve

Q/ Why did CASA (aided & abetted by the ATSB) go to such extraordinary lengths to cover-up the non-compliances and dysfunction of the PelAir FRMS/SMS dating back to at least 2004?

&..

Q/ Why did the previous CASA identified safety concerns with the PelAir FRMS that led to issue of several RCAs and even a 'safety alert' (Ref - Malcolm Campbell signed letter here: foi-ef12-10004.pdf) seemingly have no effect in addressing the systemic deficiencies identified in the - supposedly 'unauthorised' - Cook PelAir FRMS SAR?

&..finally

Q/ Within the ToR for parallel investigations - of either the 2004 or 2010 MoUs - why didn't CASA share their findings on the PelAir FRMS with the ATSB?

Excerpts from CAIR 09/3P2 comment - Note that MALIU White refers to the FRMS 'Cook' report. This would appear to contradict the former DAS McCormick's statement (sup submission) that BC was not authorised to produce the PelAir FRMS SAR?

Ironically there is not one mention of the deficiency findings of the FRMS in either the 'causal factors' or 'findings' of the CAIR 09/3 report:

To set the scene for answering my (above) QON, here is some document links for the 9 (anonymously provided) Senate AAI inquiry documents, that were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:

Quote:11
Internal CASA report titled "Oversight Deficiencies- Pel-Air and Beyond" also known as the Chambers report (dated 1 August 2010), received 10 October 2012;(PDF 6210KB)12
Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)13
Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report (dated 18 August 2010), received 10 October 2012;(PDF 1193KB)14
Internal CASA email (dated 4 February 2010) ATSB identification of a 'critical safety issue' may have ramification for CASA actions in relation to Mr James, received 10 October 2012;(PDF 913KB)15
Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (dated 11 December 2009), received 10 October 2012;(PDF 881KB)16
Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB)17
Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB)18
Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)19
CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

P2 – “[that] were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:"

Maybe I’m reading the chronology incorrectly – but it seems to me those ‘anonymous’ documents were in some kind of limbo for about 16 weeks, before being marked ‘received’, which is kind of strange anyway.

Any answers there P2 – did the docs get lost in the post? Or, have I missed a breadcrumb.

Toot toot.

I don’t expect many would ever wonder what our archives look like at the end of a week long research effort. I caught this picture of P2 hard at work Wednesday last, to give you some idea… (Big smile).

P2 – “[that] were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:"

Maybe I’m reading the chronology incorrectly – but it seems to me those ‘anonymous’ documents were in some kind of limbo for about 16 weeks, before being marked ‘received’, which is kind of strange anyway.

Any answers there P2 – did the docs get lost in the post? Or, have I missed a breadcrumb.

Toot toot.

I don’t expect many would ever wonder what our archives look like at the end of a week long research effort. I caught this picture of P2 hard at work Wednesday last, to give you some idea… (Big smile).

Quote:P2 - “From that extraordinary public hearing of revelations, obfuscating admissions, spin, bull-dust and denials, it would now appear that some of those involved individuals must have been telling the committee porky pies. This is because the existence of the Chambers Report was known at least 12 days before the first public hearing and is listed as a tabled document from CASA (i.e. 01 CASA_Doc 3_Web - PDF)”.

Of the nine documents, received by the RRAT Secretariat on 10 October 2012, I would argue that the very damning findings of the 'Cook report' far outweighed in significance and importance of the self-serving, 'cut & paste', spin'n'bulldust contribution of Wodger in the 'Chambers report'. Only now is it possible to reflect on why it was so much time and effort was given to trying to bury both the Cook and CAIR 09/3 reports...

In hindsight and based on some recent revelations/intel our breadcrumb trail is starting to thread it's way through all the deviously contrived lines of bureaucratic obfuscation and lies.
So back to those 9 docs and in particular the so called 'Cook report'.

To begin I have made some inquiries with the Senate RRAT committee Secretariat, some of which is pending on key staff return to work from hols. However I was able to establish some facts about the way submissions to inquiries were administered.

First it is very unusual for documents to be received and to then be stated as being received on the inquiry webpage. Normally documents and submissions to the committee inquiry will be processed (tabled) within days of being received. The only possible exception is when documents contain sensitive and/or private information that needs committee approval to be processed as either in camera, or redacted with the private details blanked out.

Redactions are usually able to be administered again within days of being received or tabled in public hearings. With in camera submissions a submitters consent also has be obtained and the submission will obviously not be published on the Inquiry webpage.

The advantage of in camera submissions is that the committee are immediately able to review the documents. None of the nine documents were tabled, therefore able to be reviewed by the committee, till either the day before or on the day of the extraordinary 15 February 2013 public hearing.

However all of the 9 documents, including the 'Cook report' have been redacted to protect the identities and contact details of individual officers. This led me to a question that is still pending an answer from the committee Secretariat: Q/ Are the redactions in the format/ composition that the Secretariat utilises?

Point of comparison.

These queries got me thinking about another 'Cook report' that I remember was tabled by former Senator Xenophon in the context of the 2010-11 Pilot training inquiry.

When you download the PDF you will find a pristine document that appears to have no redactions or alterations and where you 'click' on 'file' and then 'properties, you will see that PDF copy was created the day before it was tabled.

Also of interest with this particular 'Special Fatigue Audit' was that it garnered a similar negative CASA executive response to that of the Cook 'PelAir FRMS SAR'.

If the recent award of $1.25 million to a truck driver who crashed during a 430km drive home doesn’t ring alarm bells for Australian workplace standards, I don’t know what will.

The driver sued his employers based on unsafe work practice arising from forced fatigue, small recompense for a man living with structural brain damage for the rest of his life.

The incident importantly raises, not for the first time, the consistent lack of ownership for fatigue risk management (FRM) strategies across industries. I’m here to tell you we can do better.

Let’s look into the detail of the case. In the Supreme Court in Rockhampton, Justice McMeekin found both the mining company and its employment contractor liable for creating “risk by the insistence on consecutive 12-hour night shifts with…inevitable fatigue."

While the companies each denied this to their peril, Justice McMeekin found they owed a duty of care to the driver, a given under any functioning workplace health and safety law in this country. The sheer weight of mismanagement at both firms led the judge to conclude fatigue was at least a contributing cause in the accident.

So how were these companies allowed to get away with it to the point that a member of their staff has lost his livelihood? Over a number of years, I’ve been astounded by Australian businesses’ lack of proactive fatigue assurance, and their endemic incapacity to adequately monitor the effectiveness of their fatigue policies and risk controls.

While fatigue is just one hazard among a myriad that businesses need to manage, it is cases like this that show just how pivotal it is, and how important proper help can be.

Unfortunately, and compounding the issue, Australia has seen a parade of senior fatigue scientists (local gurus), with links to commercial fatigue management products. I’ve been to their sessions and what I can say is this: they’re very convincing. These so-called specialists use the words you want to hear, but trust me, they regularly deliver a false sense of security regarding your ability to actually enhance FRM.

Having seen these products consistently fail at bringing about safer workplaces, I want Australian businesses to get serious. I want our country to no longer accept the breakdown of trust in our workplaces, the endless policy and fatigue booklets, and the so-called ‘simple tools’ espoused by the safety industry gurus. They are just not good enough.

Instead, I want us to come together to build proper safety cultures into our corporate mechanisms. I want businesses to care about fatigue in their workplaces, not just manage it.

Having worked on fatigue management with elite teams including fighter combat instructors, I know first-hand the pragmatic application of FRM in an operational context, and how it can deliver the goods. From my extensive experience in this field I know that there is no effective quick fix solution to fatigue and if you seek one out you are more than likely to be disappointed in the result. Managing fatigue requires serious work in the short term for longer term success. I have learned that you can do more with less and when fatigue risk is managed well there is a concurrent improvement in the wellbeing of employees, which in turn brings with it increased productivity. This is not a zero-sum game.

My view is that if you truly want to deliver long-term, efficient work practices to combat fatigue, evidence-based FRM and enhanced sleep hygiene must be on the top of your list.

For best practice, I would look no further than real sleep and fatigue scientists like Dr Carmel Harrington, Dr Melissa Mallis, and Dr Malcolm Brenner – qualified and passionate professionals at the cutting edge of their fields. Every day I feel honoured to have them on my team at HSE3.

And to close this out, when I think what those experts could have done to help those companies to minimise the risk of this tragedy, I can’t help but feel enormously pained. With forethought, and a little management ownership, it’s easy to see how all of this could have been avoided. It’s a tragedy on so many levels.

If you are struggling with balancing the fatigue of your colleagues with the performance of your workplace, I want to hear from you sooner rather than later. As always, drop me a line at ben@hse3.com.au or simply message me on LinkedIn to start the conversation about improving your workplace.

Have a safe and happy week.

After that short but informative interlude...err back to digging -

After further digging in the Senate RRAT committee boneyard I have now come close to identifying some more PelAir morsels leftover from the 2012 inquiry...

To begin I am now waiting on confirmation that the 9 docs received on the 10 October 2012 were part of a package that was actually compiled by (what was then) M&M's department (DoIRD), on request from the Senator's - WTD??

Although slightly miffed by this revelation, as I was hypothesising that they were submitted by a whistleblower, I can now see how this chain of evidence fits with the current disjointed bones on offer...

P2 - hypotheticals X 2

Okay, so unbeknownst to both the ATSB & CASA executive management the DoIRD, at the request of the Senate RRAT committee, searches their databases for any relevant documents associated with the CASA ATSB parallel investigation of the VH-NGA ditching.

H1: Those documents are received by the Secretariat officer in charge of processing submissions. He/she decides that the nine docs contain sensitive information that needs the committee to review before being officially tabled.

On viewing the documents the committee decides that due to possible privacy and/or other sensitivity issues that the documents should be reviewed by the Minister's office and/or department for possible redaction. Although it is an extremely rare decision for a non-partisan committee to forward such documents to a government minister of the crown, this decision may have been made due to the nature of the documents and the many individual agency officers mentioned or able to be identified throughout those documents.

However normally this vetting of documents by ministerial minions would still only take a couple of days to administer so we are still left with the question of how it was those documents were not officially tabled till 4 months after they were officially recorded as being received?

H2: Those documents are received by the Secretariat officer in charge of processing submissions. He/she decides that the nine docs contain sensitive information that; a) needs to be bumped up the line for review by a superior officer. The superior officer is a mole that subsequently forwards the documents to the minister's office for further vetting and/or obfuscation for 4 months; b) needs to be forwarded to the minister's office for further vetting and/or obfuscation for 4 months i.e. the receiving officer is the mole.

(P2 comment - It could also be possible that the 9 documents had already been redacted by the DoIRD before being sent to the Senate RRAT committee.)

Unfortunately we'll have to be patient as the key Secretariat personnel that can provide confirmation of H2 (all such committee actions/decisions are recorded) are still on hols...

For the record , in the course of an active Senate Inquiry, the current on duty Secretariat staff could not recall there ever being documents/submissions being mislaid or delayed on administrative grounds, for any longer than a week or two - certainly not for 16 weeks...

MTF...P2

Ps A big thank you to the Secretariat staff members Helen & Michael who have been extremely helpful with providing information on committee inquiry processes...

Provided advice on human factors and human performance matters in the preparation of aviation regulations.

"...Coincidentally (or not) Mal Christie left CASA and started employment with the ATSB in February 2010..."

Other than being part of the PelAir special audit team and coincidentally the co-author of the PelAir FRMS SAR, it would seem that MC was the CASA officer tasked to co-ordinate the original CASA project for implementation of mandatory FRMS for certain airline/operator pax carrying operations. Here is a MC update to the Operational Standards Subcommittee meeting on 24 March 2009 (note the reference to ICAO):4.17 Fatigue Risk Management Systems (FRMS) Update

4.18 Mal Christie, Human Factors Specialist advised that the FRMS is a two phase
project. He advised that Phase 1 includes amendments to Civil Aviation Order
(CAO) 48 covering flight and duty times and guidance material implementing FRMS
for pilots. Mal advised that Phase 2 is due to commence soon for operational safety
critical personnel, and will include cabin crew, ATC, engineers, ground support and
other safety critical personnel. Mal advised that the working group is scheduled to
meet on 8 April to review the working groups proposed changes to the documents.
Mal advised that he hopes he will be able to release the NPRM in the near future
but did advise that this may not occur until we are across the ICAO FRMS SARP
update. He advised that he will be calling for nominations for Phase 2 shortly. Mal
was asked if the working group would be reviewing the ICAO documentation. Mal
said yes and subsequently advised there would be a lengthy three (3) month
consultation period due to the complex nature of the subject matter. He also
confirmed in response to a question from the SCC chair, that the Operational
Standards Sub-committee is being kept up to date on the progress by regular
briefings at its meeting.As we now know it took a further 4 years before the CAO 48.1 (FRMS) amendment was officially written into law and even then it was subject to an attempted disallowance motion by former Senator X.

Ironically the MC update was included in the minutes of an SCC 2 day meeting that was also utilised as the unofficial welcoming/coming out of the then new CEO/DAS John McCormick.

In hindsight I wonder how many of those well known Alphabet identities now cringe or have nightmares when they reflect on the following passages off the McCormick brief... :

4.23 CEO Briefing

4.24 John McCormick, CASA’s CEO attended the meeting and introduced himself toindustry members of the SCC. He added that today he had signed off an AODexemption (which had been discussed earlier under Brenda Cattle’s Alcohol andother drugs update). John added that he has recently approved the MOS conceptfor the Maintenance suite of regulations, and whilst he is philosophically opposed toa 3 tier regulatory framework, he does understand that the OLDP drafting of a 2tier framework would not have matched the industry expectations for theMaintenance suite. John referred to consultation, including CASA’s requirement toconsult under the Civil Aviation Act, and how CASA will try to take the industryalong with it on its regulatory proposals, but in the end the regulatory decisions areCASA’s to make. He encouraged industry to let him know of their ideas via the CEOfeedback available on the CASA website.

4.25 John referred to the Aviation Green Paper, which sets the target of 2010 for theend of regulatory reform. This may be very difficult and he sees regulatory reformas an ongoing process. In relation to regulatory reform John added that Australiadoes control a lot of airspace, has a thriving industry and a strong military. Headded that taking on another countries regulations style can often also mean takingon that countries social standards, which can present other difficulties in theAustralian context. He advised that at this stage it is ‘business as normal’ and thatCASA will try to move the regulations forward, take input and consult, once againas required under the Civil Aviation Act. He also advised that he wanted toencapsulate a review of the enforcement regime, though this may not be a highpriority but does need to be addressed at some stage. John then went onto speakabout the structure of CASA and how with any organisation working through areform process there is always some reworking required, particularly in relation tohow CASA works with industry. John was very mindful of having a single point ofcontact as he is aware that often industry may liaise with several offices withpossible varying outcomes. John then added that he saw the Australian aviationindustry as robust and expressed support for the GA sector of industry withinAustralia, as it is the backbone that must not be left behind. John also mentionedthat he intends reviewing the oversight of different sectors of industry.
What I find passing strange is that in the next SCC meeting on July 29 2009 there was no further update on the FRMS project, this was despite the fact ICAO were ramping up their campaign to mitigate fatigue risk in the aviation industry. (This included the establishment of a FRMS taskforce in November 2009)

However I guess we shouldn't be surprised when we saw McCormick's attitude to FRMS and the input to fatigue oversight from certain former CASA HF experts..

One area of interest from the July SCC meeting was this:

6.1 ICAO Audit Findings PEL/02 - ALAEA

6.1.1 John Alldis representing ALAEA spoke to this item questioning what action CASA had taken to address the issues raised in the ICAO Audit in relation to CASA surveillance of delegated licensing activities and approved training organisations also taking into account the proposed implementation of competency based training in relation to licensing. John also questioned how CASA’s timetable was progressing on the ICAO findings and the recommended actions. Peter Boyd advised that CASA has already made a move on this issue, given the implementation of the new rules, he advised there are some synergies, but CASA has a comprehensive surveillance plan in place. Peter reassured members that CASA does have adequate resources and the transition will be properly managed, and resources appropriately applied. As part of CASA’s realignment it is also looking at resourcing on these transition type activities. John reiterated ALAEA’s concern given his quoted drop in numbers of Airworthiness
inspectors (AWIs) from 100 to 60. Peter undertook to confirm numbers and come
back to the SCC on this issue. In relation to the ICAO Audit findings Peter confirmed
that CASA has provided its response in relation to the Corrective Action Plan in late
2008, and is currently monitoring the implementation of the corrective actions within
CASA, as part of this plan.

Action Item: July 09-1. CASA to report back on AWI numbers in relation to CASA
being able to effectively implement and oversight delegated licensing activities and
approved training organisations.
Fast forward that to 7 December 2009 when this WikiLeaks cable was revealed: https://www.wikileaks.org/plusd/cables/0...081_a.html

Two weeks later Ben Cook and Mal Christie submitted their PelAir FRMS special audit report which I can now confirm they were tasked to complete as part of the PelAir special audit.

However on returning from leave the two CASA HF experts were informed that the report would no longer be included as part of the final audit report...

In summary, the Instrument is a step in the right direction but is unfinished business. There are serious concerns about the application or otherwise of the body of fatigue science and research and the preservation or extension of existing provisions already challenged by parts of the industry as unsafe.

CASA has an abysmal record of regulatory oversight of fatigue management, even without the pressure of trying to get some serious traction on the Regulatory Reform programs that have diverted them for the last 17 or so years. Parts of the industry believe that CASA has seriously underestimated the resources required to implement these new rules and that there will be an inevitable trade-off in surveillance activities of flight operations.

If not disallowed now, this legislation will continue with no incentive for improvement unless and until the inherent risk crystallises into an undesirable outcome. That is not a possibility that this Parliament should allow to persist.

From pg 5:

ICAO recognises the importance of “operational experience”, but that is a tainted concept if it merely reflects what operators have been doing or what the regulator thinks they are doing.

In Australia, we have already seen how this concept is tainted - recent Senate inquiries that have touched upon Jetstar, Pel-air and Avtex/Skymaster fatigue management processes and largely exposed the gulf between sound fatigue risk management, what operators have really been doing and what the regulator didn’t really bother to see what they were doing. The CASA Special Audit conducted after the Pel-Air ditching revealed all three of those propositions, while explaining a lack of pilot complaints:

Quote:…The short planning period, lack of knowledge of possible destinations and lack of support provided by operations staff once doors closed appears to add to this fatigue. All crew interviewed stated that they felt there would be no issues in stating that they were fatigued and pulling out of duty but also felt that they had limited opportunities to fly and had to take these opportunities when they arose… 8

… Most crew interviewed stated that they had been part of a duty that was greater than 15 hours in length but evidence could not be identified that showed fatigue related extension of duty processes had been followed, safety reports had been written following the duty or that management follow-up was conducted as is required in the company FRMS manual. Several interviewees believed that there is a lack of management adherence to safety management requirements and the fatigue risk mitigation strategies as laid down in the company's FRMS manual…9

When CASA was asked about the significance of Jetstar requiring crews on the Darwin-Singapore-Darwin night flight to extend beyond their normal flight duty period (FDP) limits on 12 of 21 flights in January 2011, they responded:

Quote:CASA does not consider that these extensions require continual monitoring.
The duty extensions recorded in January 2011 by Jetstar were a result of flight crew agreeing to operate beyond the standard 12 hour initial limits as provided for within Civil Aviation Order 48 Exemption. No breaches of the 14 hour condition were recorded.10

Undoubtedly that is how CASA will regulate operations under the SIE until they expire in 2016, despite the fact that the same flights could not even be contemplated under The Instrument! Finally, from evidence given to the UK Parliament Transport Committee Inquiry into Flight Time Limitations in February 2012 (which we believe to be replicated in parts of the Australian industry):

Quote:7.6. More importantly: fatigue is significantly under-reported by the pilots themselves. This is because pilots do not file reports on an aspect that has become a ‘normal’ part of their daily work. Many are afraid their fatigue reports could have negative consequences for their professional future (i.e. reprisals by management) – a phenomenon that is growing – particularly when pilots refuse to fly because they are too fatigued. Indeed UK polling results show that 33% of pilots would not feel comfortable refusing to fly if fatigued, and of those who would, three quarters would have reservations. Once a pilot has decided they have no option but to fly, a fatigue report would be tantamount to writing the evidence for their own prosecution…11

This under-reporting by pilots is exacerbated by CASA being widely seen by the aviation community as having actively disengaged in any intelligent discussion about fatigue regulation for many years. It is highly unlikely that CASA has any defensible
‘regulatory experience’ other than superficial ‘tick and flick’ audit activities and, as such, cannot and should not rely on its perception of the current state of fatigue management to set aside the science or to replicate current rules.
Spot the FRMS dots & dashes? If you have any remote interest in the subject I recommend taking the time to read the AIPA Parliamentary brief in it's entirety...

A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.

Transcript

KERRY O'BRIEN, PRESENTER: The Federal Government has set out its vision for the aviation industry over the next 20 years in a white paper dealing with issues from in-flight security to the seemingly endless quest for a second Sydney airport.

But there's another big issue looming for the aviation industry: pilot fatigue, which has been linked to a series of accidents around the world over the past decade.

The International Council of Aviation will put in place new rules next year to manage pilot fatigue in one of the biggest shake-ups in 50 years of commercial aviation.

In 2001, Australia was ahead of the game, introducing a five-year study into the issue. It recommended a whole new approach to the management of pilot fatigue.

But many of those who took part are now musing as to why Australia is still waiting to see what the rest of the world will do.

Thea Dikeos reports.

RICHARD WOODWARD, AUSTRALIAN & INTERNATIONAL PILOTS ASSN: Someone said to me once, "If you want to think about what we do, sit in front of a fish tank at 4 o'clock in the morning and stare at the fish for two hours and see how you feel."

THEA DIKEOS, REPORTER: It was the close call that shocked the Flying Kangaroo's renowned safety record. In 1999, a Qantas 747 overshot the runway at Bangkok, injuring 38 of the 400 passengers on board.

The Australian Transport Safety Bureau investigated the incident and revealed the pilot had been awake for 21 hours and the first officer 19 hours. But the incident report found there was insufficient evidence to conclude fatigue was the cause.

JOHN GISSING, SAFETY MANAGER, QANTAS: We took action after those findings. Fatigue risk is one of the mentions in that report. In the mix of our safety improvement strategy was clearly something that we were very keen to learn more about.

THEA DIKEOS: 10 years on, pilot fatigue is at the forefront of the international air safety agenda. Next year, the global body responsible for air safety standards, the International Civil Aviation Organisation, will announce one of the most significant shake-ups in 50 years of commercial aviation.
It's expected to issue guidelines requiring member countries to incorporate scientific analysis to assess pilot fatigue. Australian airlines will also need to comply.

RICHARD WOODWARD: They'll be the biggest single change in flight time limitations and the risk management of those since the 1950s.

THEA DIKEOS: Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

JOHN MCCORMICK, CIVIL AVIATION SAFETY AUTHORITY: If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority.

RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

THEA DIKEOS: With more than 20 years military and commercial flying experience, Qantas pilot Richard Woodward is providing input for the proposed new international standards. On the ground, he likes to race vintage Monaros.

RICHARD WOODWARD: I've been flying long haul aeroplanes for 24 years or so and, yes, there's times when you feel terrible when you're sitting in an aeroplane, you're just so tired that you feel physically ill.

THEA DIKEOS: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.

RICHARD WOODWARD: At the time it was world's best practice research.

THEA DIKEOS: More than 260 volunteer pilots took part in the study.

DREW DAWSON, SLEEP RESEARCH, UNI. OF SA: We wanted to know how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance.

MATTHEW THOMAS, SLEEP RESEARCH, UNI. OF SA: I have been have on a flight deck where both pilots have been asleep.

THEA DIKEOS: It was this experience years earlier on another research project which prompted Matt Thomas' interest in pilot fatigue.

Can you understand from a person who flies who's in the passenger seat that that might be a bit alarming?

MATTHEW THOMAS: Absolutely. Fatigue is a very real issue in aviation, without a doubt.

THEA DIKEOS: Over 50 years, a complex formula has been used to determine how long pilots can work and how much rest they should have. The Qantas study found that didn't tell the whole story.

DREW DAWSON: We collected data that said even though pilots are compliant with the rules, there are a small number of occasions when they aren't actually getting sufficient sleep to be safe.

MATTHEW THOMAS: The roster simply does not predict at all well a crew's performance. We saw that in the simulator very clearly.

THEA DIKEOS: Disturbingly, the researchers found pilots who had less than five hours' sleep were twice as likely to make safety errors.

MATTHEW THOMAS: Incorrect calculations is a classic example, well known to cause accidents internationally, errors in decision-making.

THEA DIKEOS: Are there many pilots in Australia flying under those circumstances?

MATTHEW THOMAS: The broader studies which show us that it's a small percentage, but every day there would be some. It's in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots.

THEA DIKEOS: This year, Virgin Blue introduced a new fatigue risk management system. Pilots are now trained to assess their own fatigue.

ANDREW DAVID, VIRGIN BLUE: How many hours have you been awake before you start this tour of duty, verses how many hours you've slept in the last 24 and 48 hours. So a simple report card and a mechanism to be able to report fatigue.

THEA DIKEOS: Richard Woodward and the South Australian researchers say they're disappointed that Qantas and CASA didn't move quickly to address all the recommendations in the South Australian report.

RICHARD WOODWARD: We fully expected the airline to move ahead and implement that. We also expected the regulatory authority to move ahead and change the rule-making process. They did start to do that and I participated in that as well and we drafted a set of rules, but then the program basically ceased until we see what happens at ICAO.

THEA DIKEOS: Qantas rejects the criticism and says it's implemented 15 of the 30 recommendations from the report and says it's well placed when the new regulations come in 2010.

JOHN GISSING: We'll be well ahead in terms of the full implementation of our further improvements that we're planning at the moment.

JOHN MCCORMICK: We don't want to make industry or individuals be placed in a situation where this year, say, we mandate something and then find next year the international standard is something different.

DREW DAWSON: I think we know enough about what's likely to come out of the draft regulations and proposed rule-making initiatives to say we could have a pretty fair guess on how to move forward.

DREW DAWSON: I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don't wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way.

In all good detective yarns the motivation is treated as a major key to solving ‘the puzzle’. It makes good sense to do so, the reason why and qui bono always make good starting places. The chronology HERE defines ‘the act’; but fails to provide ‘the motivation’. To work that out we must, once again, look to the past.

ICAO had gone ‘big’ on pilot fatigue, identifying it as a major concern; and thanks to the good work of some clever folk, Australia was well positioned to shine. However, the period preceeding the ditching had been ‘difficult’ for the ‘watchdog’. The ICAO audit had kicked seven bells out of CASA – McComic reacted and requested an IASA (FAA) audit – to balance the scales and cover Albo’s sorry arse. FAA was not impressed and McComic’s little scheme backfired. The threat of downgrade was very, very real. Government (taxpayer) money and some hefty diplomacy bought a reprieve. But make no mistake – Australia was up to it’s hocks in alligators.

Then came the ditching off Norfolk Island. Any serious investigation into systematic flaws would reveal and confirm the worst fears of the ICAO and FAA audits. Although the mystery of two resignations and the decision to discard some fairly important reports is yet to be solved, there remains one curiously intriguing element yet to be satisfactorily resolved. I will leave providing the ‘dots’ up to P2 (patience, patience). I will make a dash toward a conclusion, the reader may make of it what they will.

That all survived the ditching was most inconvenient; the event had to become ‘pilot error’. Suddenly to protect the ICAO status, the home grown reports which revealed serious flaws in Australia’s approach to and ignorance of FRMS and SMS were a liability. Further independent analysis of CASA’s sloppy handling of the historical flaws in Pel-Air operational management would have shone a bright light into exactly the wrong corner, at precisely the wrong moment. Even so: had there not been a Senate inquiry, the whole event would have been neatly brushed under the carpet.

There had to be a reason for the bizarre, extraordinary behaviour of CASA following the Norfolk ditching event. The life and career of one small, insignificant human became as nothing when compared to the truly shocking notion that the world may discover how seriously flawed the regulator, the regulation and the management of aviation truly was then. It will come as no surprise that nothing – absolutely nothing has changed since then; unless you count the slow, irresistible slide deeper into the pit. Do I feel sorry for the ‘good eggs’ in the CASA basket? No, I do not. ‘They’ could have spoken out, they have had ample opportunity and much encouragement to do so. Resignation and silence – honourable? Oh, I think not.

“Mine honour is my life; both grow in one.Take honour from me, and my life is done.”

"...There had to be a reason for the bizarre, extraordinary behaviour of CASA following the Norfolk ditching event. The life and career of one small, insignificant human became as nothing when compared to the truly shocking notion that the world may discover how seriously flawed the regulator, the regulation and the management of aviation truly was then. It will come as no surprise that nothing – absolutely nothing has changed since then; unless you count the slow, irresistible slide deeper into the pit. Do I feel sorry for the ‘good eggs’ in the CASA basket? No, I do not. ‘They’ could have spoken out, they have had ample opportunity and much encouragement to do so. Resignation and silence – honourable? Oh, I think not..."

HVH:“By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,”

Is that like the ATSB closing safety loops on serious safety issues that having been identified, in some cases nearly 2 decades ago, & despite political and aviation safety bureaucratic rhetoric, are yet to be effectively risk mitigated...

Quote:Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.
& answer to Supp Estimates QON 157 (note that this was 6 days before the AAI inquiry began):

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.
Mr Mrdak: It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.

Answer:

One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed, not addressed, no longer relevant or withdrawn.

A safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required.

The ATSB policies and procedures for identifying and promoting safety issues, including through the issuance of a formal recommendation, is outlined in its submission to the Senate References Committee Inquiry into Aviation Accident Investigations.

The ATSB’s Annual Plan and part of the ATSB’s Key Performance Indicators specifically relate to a measurement of safety action taken in response to safety issues; in the case of ‘critical’ safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.

As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for following up on recommendations and safety issues identified by the ATSB, as provided for in the Memorandum of Understanding between the agencies. Aviation safety agency heads will continue to monitor the present arrangements to provide an adequate system for addressing issues identified through ATSB investigations.

Coming back to the - unclosed loop - 2 decade old identified safety issue of fatigue, as a passing strange coincidence the following was a short passage of Hansard, from May 2012, that followed Sen Fawcett's ATSB safety loop questioning:

Quote:Senator XENOPHON: I will try to make it a very quick one. I keep getting complaints from those who are in safety-sensitive positions in aviation about fatigue issues and that the fatigue issues seem invariably to accompany reports of an oppressive workplace culture, most recently in terms of air traffic controllers. How does the ATSB deal with the particular issues of fatigue management and the performance consequences of workplace culture, given the subjectivity inherent in those concepts? Do you see a role in ATSB monitoring the performance of the fatigue management systems or do you see it as a purely regulatory function? Do you think that the regulatory agencies are doing enough about fatigue risk management? I am happy for you to take it on notice.

Mr Dolan : With your indulgence, I can answer it quite quickly.

CHAIR: Yes, get to the point.

Mr Dolan : Fatigue, when it is detected as a contributing factor in any investigation we undertake, we will look to fatigue management systems to see whether they can be improved to better manage the risk of fatigue in the system. I do not have any evidence in front of me that would allow me to give you an additional comment on the adequacy of regulatory oversight. We have not seen anything that would say it is inadequate. P2 comment - Err (vomit - ) BOLLOCKS!!

Also of much historical interest was this passage from earlier in the ATSB session:

Quote:Senator XENOPHON: It has been suggested to me that, with the ATSB's pursuit of no-blame results in reports, on the one hand they are delayed by seeking high levels of consensus amongst interested parties and, on the other hand, they could potentially end up lacking human factors reporting as to risk, rendering the reports almost as historical records rather than safety enhancement tools. Could you comment on that? Is the amount of time spent on consulting interested parties detracting from the timeliness of publishing reports? I know there are some tensions here in terms of due process and fairly helping people. I have tried to set out what the concern is.

Mr Dolan : I hear two elements to your question, so I will take them sequentially. The key process of consultation is done at the point where we have a draft report. So we have examined all the facts, we have done our analysis and we have formed provisional views. We circulate a draft report under the protection of our act—so not to be released—to what we call directly involved parties. If it is domestic, we expect any comments within a month and we emphasise that we are principally seeking any corrections of factual inaccuracies in our report. We are also seeking, where we have identified a safety issue, information on any action that the relevant party may have taken in response to the identified issue. The focus is on getting something done in response to our findings. That process normally takes a month plus another week or two to make sure that the relevant concerns that may have been raised with us are integrated into the final report. I do not see it as a major constraint on our timeliness.

Senator XENOPHON: You do not think it constrains you in terms of providing more depth in human factors analysis?

Mr Dolan : That was the second part, as I was saying, of the question. There is the specific timeliness thing, an appropriate level of review to make sure that the rigour and the factual accuracy of our reports is in place, which I think is important, and it also goes to procedural fairness. Although we are a no-blame organisation, people can read our reports as pointing the finger, even though we do not intend them to. So there are no surprises for those involved.

The second point is that I am startled that there is a belief out there that we do not have human factors at the core of what we do. Our entire investigation and analytical model is based on fundamental principles of human factors—understanding human error, understanding how to minimise it, accepting that you can never remove it, and looking therefore at how you capture errors and make sure they are dealt with in the system. I am not sure, in addition to that, how much I can say.

Senator XENOPHON: I will possibly put some questions on notice about Airservices Australia. In relation to that issue of human factors, it was not a criticism; I am just saying that was a concern that has been expressed to me by those in aviation. I am thinking of the Air France 447 investigation, which of course the ATSB has nothing to do with—that terrible loss of life over the Atlantic.

Mr Dolan : We are watching it with interest.

Senator XENOPHON: No doubt you are looking at it with interest. You correctly emphasised factual information. With Air France 447, I think there is still a final report down the track?

Mr Dolan : The report is due for release next month, as I understand it, from Mr Troadec of the BEA.

Senator XENOPHON: That whole investigation seems to be looking at human factors. It seems increasingly clear that the 'what' does not so much clarify the 'why'. To what extent will the 447 investigation influence the way that air safety investigators around the world conduct their work, or is it just an instance of human error?

Mr Dolan : I suppose this might help you in explaining my puzzlement. I have had conversations from time to time with my French counterpart, Mr Troadec. I would totally agree with you that some of the key issues in Air France 447 relate to human factors—understanding why some of the various actions that were clear from the flight data recorder and the cockpit voice recorder, once retrieved, happened. The reason I remain puzzled is that the 'why' is at the heart of what we are trying to do. We normally get the 'what' in the initial occurrence report. The time we take is to try to understand the 'why' and whether anything needs to be done as a result of us having determined the 'why'.

Q/ Can anyone else see the irony of the 'Beaker' weasel words?

Again remember that this was approximately 5 months before the Senate PelAir inquiry began; and a year before the diabolical findings of that inquiry were made public; and about 13 months before AIPA presented their Parliamentary Brief on fatigue and the proposed disallowance motion on the CAO 48.1 legislative instrument...

Extract from PelAir MKII FR:

Quote:...On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation...
& from Oz Aviation 8 December 2014:

“A new investigation team will review the original investigation and associated report in the light of any fresh evidence and relevant points raised in the TSB review and other recent aviation reviews,” the ATSB said in a statement on Monday.

“At the same time, the ATSB Commission will continue to methodically and carefully work its way through the broader findings and recommendations of the TSB review, with the aim of ongoing improvements to the future work of the ATSB.”

A Senate committee also the released a scathing assessment of the original investigation.Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss told Parliament last week he had asked the ATSB to reopen the case.

To be continued: Next I will again fast forward to the PelAir MK II Final Report to factually expose how the ATSB has once again obfuscated it's stated responsibilities to the re-investigation (see above) and the primary purpose for ICAO Annex 13 Aviation Accident Investigation. IMO the PelAir FR, in particular on the downplaying of fatigue & SMS identified safety issues, provides further proof that the ATSB is still continuing in the role of providing top-cover for the regulator CASA, the Department and indeed the Minister...

P2 -"IMO the Pel-Air Final Report; in particular; the downplaying of fatigue & SMS identified safety issues, provides (IMO) further proof that the ATSB is still continuing the role of providing top-cover for the regulator CASA, the Department and indeed the Minister"..

Nah! – wrong way round P2. The minister is always the first protected; otherwise – what use are ATSB and CASA – if not to protect the shiftless, lazy, only interested in retaining power government. Many governments have had an opportunity to resolve the three decade long problem of ATSB, CASA and the “safety” argument. All failed; beaten by a bunch of ‘expert’ opinion which they have never gainsaid or even bothered to question. Why would they – they’re safe behind the Iron Ring. That class of top cover costs a fortune and the tax payer meets the bill – all in the name of “safety” of course.